Oral submucous fibrosis (OSMF) is a chronic, insidious, disabling disease involving oral mucosa, the oropharynx, and rarely, the larynx.[1] It is exclusively reported in Indian population.[2] The disease is characterised by blainching and stiffness of the oral mucosa, trismus, burning sensation in the mouth, hypomobility of the soft palate and tongue, loss of gustatory sensation, and occasionally, mild hearing loss due to blockage of Eustachian tube More Details.' A variety of aetiological factors including capsaicin, betal nut alkaloids, hypersensitivity, autoimmunity, genetic predisposition (HLA-A 10 , DR 3 , DR 7 and halotypes A 10 /DR 3 , B, 3 /DR 3 and A 10 /B 8) and malnutrition have been suggested by various authors. Ramnathan has suggested that OSMF may be a mucosal change secondary to chronic iron deficiency calling it an Asian analogue of sideropenic dysphagia.[1],[3] It has also been suggested that it is a nonspecific inflammatory reaction to trauma yet the exact aetiology is unknown.[4] The disease can be classified clinically into two phases (1) An eruptive phase, characterised by formation of erythema, vesicles, ulceration and a burning sensation in the mouth. (2) The fibrosis induction phase, characterised by the disappearance of the vesicles and healing of the ulcers by fibrosis. The burning sensation decreases and blanching and stiffness of the oral and oropharyngeal mucosa occur. The two phases appear in a cyclic manner.[1]

Case Reports

Case 1

A 35-year-old man, resident of Punjab presented in Skin and V .D. O.P.D. with difficulty in opening the mouth since 1 year. He started having burning sensation over the mucous membrane on right side with chillies and smoking 3 years back. After 6 months, he developed superficial erosions in the mucosa on right side. The erosions subsided with tablet dapsone and some oral paint. Since then he was having restricted movements of the cheek on right side. Patient was a chronic smoker for the last 20 years and was smoking about 15-20 bidis per day. There was no history of any other skin lesion or other mucosal involvement. On examination, the mucous membrane on right side was smooth, shiny and pale while on left side it was normal. On palpation, the mucous membrane of right cheek was firm and there was a fibrous band extending from the buccal aspect of molar area upto the angle of mouth. Oro-dental hygiene was poor but all the teeth were intact. The movements and opening of the mouth was reduced on the right side.

All the routine investigations were normal except haemoglobin which was 8.0 gm%. Biopsy from right buccal mucosa showed atrophy of the stratified squamous epithelium. In the juxta-epithelial part there were present fibrous bands. Bands of fibrous tissue could be seen extending in between salivary gland lobules. No appreciable inflammatory tissue was seen. No dysplasia was seen.

Case 2

A 20-year-old man, resident of Uttar Pradesh, presented with 2 year history of burning sensation in the oral mucosa with chillies and difficulty in opening the mouth on right side since 1 year. No history of any mucosal erosion or ulcers was present. History of chewing tobacco with lime and arecanut was there for the last 5 years. He used to keep betel leaf with slaked lime and arecanut in the form of paan on right side 5-6 times a day. On examination, the right side oral mucosa was white and shiny. No erosions or ulcers were seen. The surface was smooth but firm on both sides. On right side, against the buccal aspect of molar teeth there was a firm band extending from the molar area upto the angle of mouth. The opening of the mouth was reduced. All the routine investigations were normal except haemoglobin which was 9.2 gm%. Biopsy from the right buccal mucosa showed atrophied stratified squamous epithelium. Underneath the stromal tissue there was infiltration by inflammatory cells predominantly showing lymphocytes. Towards the deeper parts there was fibrosis.

Discussion

Oral submucous fibrosis is one of the most poorly understood and unsatisfactorily treated disease. An estimated 2.5 million people suffer from the disease in India.[1] The importance of this disease lies in its inability to open the mouth and dysplasia giving rise to malignancy. The incidence of malignant change in patients with OSMF ranges from 2 to 10%.[2] The younger the age, the more rapid the progression of the disease. All the available treatments give only symptomatic relief, which too is short lived.[4] Areca­nut chewing, tobacco smoking and hypersensitivity to chillies are the precipitating/causative agents in genetically predisposed patients. So habit restriction should be there in clinically suspected cases, to retard the disease process and as it is a premalignant condition, there is need for careful observation and follow up in each and every case.